陳人傑¹、黃子豪^1,2、黃志賢^1,2

臺北榮民總醫院 泌尿部¹; 國立陽明大學醫學院 泌尿學科 書田泌尿科學研究中心²

Jen-Chieh Chen¹, Tzu-Hao Huang^1,2, William J. Huang^1,2

¹ Department of Urology, Taipei Veterans General Hospital; 

² Department of Urology, School of Medicine and Shu-Tien Urological Institute, National Yang-Ming University, Taipei, Taiwan

We report a rare case of bladder perforation by metallic wire of septopal beads after hip joint debridement and bone cement implantation.

This is a 60-year-old man who received right total hip replacement in 1995. Six months ago, he was diagnosed with septic arthritis and received implant removal, wound debridement, and bone cement implantation at other hospital. This time, he presented to our emergent department due to recurrent right hip redness and swelling. He did not have fever, chillness, cough, dysuria, or abdominal pain. The complete blood count showed markedly leukocytosis with neutrophilia, and his serum level of procalcitonin was 11.2 ng/ml. Urinalysis showed pyuria with bacteriuria. Pelvic computer tomography (CT) showed (1) destructive change of right hip joint with post-operative change and implanted antibiotic beads; (2) suspicious fluid content in right hip joint area. Septic arthritis and asymptomatic bacteriuria were impressed. Arthrotomy with hip joint debridement was done by orthopedist and Vancomycin-Ceftazidime beads were placed into hip joint space. Both urine culture and joint fluid culture yielded Proteus mirabilis with similar antibiotic susceptibility. His condition improved after antibiotic treatment and surgery. However, on the nineteenth day after surgery, the Foley catheter was removed and the amount of hemovac drain of right hip joint increased significantly (about 1000 ml per day). Pelvic CT was arranged again, and a 0.8 cm radiopaque round lesion was noted in urinary bladder. Cystoscopy showed the bladder was impaled by a metallic wire over right lateral wall and a septopal bead was found in the bladder. Thus he underwent emergent surgical intervention on the same day. During the surgery, the right bladder wall adhered to right pelvic side wall severely and the tip of the penetrated wire could be palpated inside the bladder after cystotomy. Complete adhesiolysis of bladder wall from the pelvic side wall was not feasible. A small piece of bladder tissue and wire tip was thus left on the pelvic side wall and the bladder wall defect was then repaired. The patient was then put into lateral position and the wire was removed by orthopedist via Watson-Jones approach. The patient tolerated the surgery well and was discharged with indwelled Foley catheter afterward. Follow-up cystography one month later showed good healing of the bladder and no urinary leakage.

Tracing back his history, the bladder wall might have already been exposed to the hip joint cavity during the first debridement 6 months ago, followed by progressive destruction and subsequent abscess accumulation as a result of possible fistula formation, which could be identified on the initial image that the bladder wall was tightly adjacent to the septopal beads on presentation at our hospital. The similar results for urine and abscess culture gave us an indirect evidence. Therefore, the bladder rupture might be inevitable after the second debridement ultimately.

There are no prior case reports describing bladder perforation by metallic wire of septopal beads after hip joint debridement with bone cement implantation. This case report highlights the importance of surgeon awareness of an unusual complication. This patient was treated successfully with partial cystectomy and had an acceptable outcome.